2022 Employee Enrollment Guide (PEBB)

1 Your PEBB benefits for Employee 2022 Enrollment Guide Quick start Guide Page 5. 2022 Monthly premiums Page 31. Eligibility Pages 8 12. Medical plans by county Page 28 30. Medical benefits comparison Pages 32 36. Enrollment forms At the end of the Guide HCA 50-0100 (11/21). Who to contact for help Contact the health plans for help with: Contact your payroll or benefits office for help with: Benefit questions Eligibility for coverage and Enrollment questions or ID cards changes Claims Accessing paper forms Checking to see if a health care provider is in the plan's Premium surcharges questions network Updating your contact information (name, address, Choosing a health care provider phone, etc.). Making sure your prescriptions are covered Enrolling or removing dependents payroll deduction information (including pretax or post- tax contributions).

2 Appeals (Also see page 59.). Medical plans Dental plans Health savings account (HSA). for consumer-directed health Kaiser Permanente NW1 Classic or DeltaCare plans (CDHP). CDHP Administered by Delta Dental of Washington HealthEquity 1-800-813-2000 (TRS: 711) 1-800-650-1583 (TTY: 1-800-833-6384) 1-844-351-6853 (TRS: 711). Kaiser Permanente WA Classic, CDHP, SoundChoice, or Value Uniform Dental Plan Life and AD&D insurance Administered by Delta Dental of 1-866-648-1928 Washington Metropolitan Life Insurance (TRS: 711 or 1-800-833-6388) Company (MetLife). 1-800-537-3406 (TTY: 1-800-833-6384) Enrollment and management: Uniform Medical Plan (UMP) Classic, Select, or CDHP Willamette Dental Group Info, docs, and more: Administered by Regence BlueShield and Washington State Rx Services 1-855-433-6825 (TRS: 711) 1-866-548-7139.

3 Medical services: Auto and home insurance Long-term disability 1-888-849-3681 (TRS:711). (LTD) insurance Prescription drugs: Liberty Mutual Insurance Company Standard Insurance Company benefits/prescriptions benefits/employees/auto-and- 1-888-361-1611 (TRS: 711) home-insurance state-hca-pebb 1-800-706-5525 1-800-368-2860. UMP Plus Puget Sound High Value Network Medical Flexible Spending voluntary wellness program Arrangement (FSA), Limited 1-855-776-9503 SmartHealth Purpose FSA, and Dependent Care Track activities: Assistance Program (DCAP). UMP Plus UW Medicine Accountable Care Network Navia Benefit Solutions Eligibility and deadlines: 1 888-402-4237 (TRS: 711) 1-800-669-3539 or 425-452-3500 1-855-750-8866. HCA is committed to providing equal access to our services.

4 If you need an accommodation, or require documents in another format, please contact your payroll or benefits office. 1. Kaiser Foundation Health Plan of the Northwest (KFHPNW) offers plans in Clark and Cowlitz counties in Washington and select counties in Oregon. 2. Welcome The PEBB Employee Enrollment Guide will provide you with information you need to sign up for, use, or change your PEBB benefits. Please keep this Guide for reference. An online version is available on the PEBB webpage at Newly eligible employees have 31 days to enroll in PEBB. benefits. In addition, the annual open Enrollment in the fall provides an opportunity for you to change your plans, add or remove dependents, and make other changes. You can also make changes during a special open Enrollment if you have a qualifying life event.

5 See Changing your coverage . on page 51. For information about options for continuing insurance coverage once your or a dependent's eligibility for PEBB. benefits has ended, see When coverage ends, on page 56. The PEBB Program is managed by the Washington State Good to know! Health Care Authority (HCA). PEBB My Account is changing In spring 2022, PEBB My Account will be updated to a more user-friendly and user-directed application. With the improved PEBB My Account, you will enroll in and view benefit elections, make changes, upload forms and documents, attest to premium surcharges, request changes due to special open enrollments, and other functions. Watch for announcements on the HCA website at for how to sign up for and use the updated PEBB My Account.

6 3. Table od Contents Who to contact for help .. 2. 3. Quick start Guide .. 5. Enrollment checklist .. 7. Employee eligibility .. 8. Dependent eligibility .. 10. How to enroll .. 13. Medicare and PEBB .. 15. Waiving Enrollment .. 16. Paying for 18. Premium surcharges .. 20. Choosing your benefits .. 22. Selecting a medical plan .. 23. CDHPs with an HSA .. 25. Behavioral health coverage .. 27. 2022 Medical plans available by county .. 28. 2022 Monthly premiums .. 31. 2022 Medical benefits comparison .. 32. Selecting a dental plan .. 37. 2022 Dental benefits comparison .. 38. Life and AD&D insurance .. 39. Long-term disability insurance .. 42. FSAs and 45. SmartHealth .. 47. Auto and home insurance .. 48. After you enroll .. 49. Changing your coverage.

7 51. When coverage ends .. 56. Appeals .. 59. Enrollment form links .. 61. 4. Quick start Guide Use this for an overview of the Enrollment process. To enroll your spouse, state-registered domestic partner, Watch for references to page numbers where you'll find or children, you will need to provide their: more information. Look for the Good to know! boxes Name throughout this Guide for quick tips, definitions, and Date of birth additional information. Social Security number 1. Find out if you're eligible Verification documents. Make sure you have the right To be eligible for PEBB benefits, you must meet the criteria documents on hand to prove their eligibility. These described in PEBB Program rules. Your employing agency documents are listed on page 11.

8 You may need to will determine if you are eligible for PEBB benefits based on submit additional forms. See Additional required forms your specific work circumstances. See Employee eligibility for dependents on page 13. on page 8 for more information. 4. Choose your health plans 2. Learn about your benefits A list of the benefits available to eligible employees is on Health plans available to you page 7. For information on the plans available to you, see You will pay a monthly premium for medical coverage, Selecting a medical plan, on page 23 and Selecting a which includes vision. Your employer pays part of the dental plan, on page 37. premium for medical, and all of the premiums for dental Check 2022 Medical plans available by county, on coverage, basic life insurance, basic accidental death and page 28, to see what plans are available to you.

9 To enroll dismemberment (AD&D) insurance, and employer-paid long- in a Kaiser Permanente plan, you must either live or work term disability (LTD) insurance, if your employer offers them. in one of the counties where it is offered. For UMP Plus, you You will pay monthly premiums for any supplemental must live in one of the counties where it is offered. Dental ( Employee -paid) coverage you are enrolled in. See Paying availability is based on the network the dentist participates for benefits on page 18. in, rather than where you live or work. You may be able to waive PEBB Enrollment if you have Compare health plan benefits and costs other group coverage. See Waiving Enrollment on page 16. A list of medical plans and premiums is on page 31. Exception: Employees who work for an educational service Good to know!

10 District, city, county, port, tribal government, water district, hospital etc., need to contact their payroll or benefits office You will be automatically enrolled in Employee - to find their monthly premiums. paid LTD insurance The 2022 PEBB Medical benefits comparison starts on page 32. The Dental benefits comparison is on page 36. Starting January 1, 2022, all current and newly These charts give you some basic cost information about eligible employees will be automatically enrolled deductibles and cost-shares so you can compare plans. in or transitioned to an Employee -paid long-term disability (LTD) plan that covers 60 percent of Learn more your predisability earnings, with a 90-day benefit If you need more details, refer to other sections of this Guide .